Disclosures: Lauren A. White, DO, MPH: Nothing to disclose

Case Description: Patient presented to outside hospital with bilateral radiating leg pain and numbness and saddle anesthesia. Magnetic resonance imaging (MRI) lumbar spine showed severe central canal stenosis and nerve root clumping at L3-4, L4-5 and L5-S1. He was transferred to our facility for additional management. History was consistent with cauda equina syndrome but initial exam revealed proximal lower extremity weakness, intact distal strength, rectal tone and sensation, and hyperreflexic patellar reflexes. He underwent L3-L5 laminectomy, partial medial facetectomy and foraminotomy with fusion and was transferred to inpatient rehabilitation (IPR). He continued to be hyperreflexic with proximal lower extremity weakness. MRI cervical spine showed large C6-7 disc herniation causing cord compression and edema; underwent C5-7 anterior cervical discectomy and fusion (ACDF). Again admitted to IPR where his lower extremity strength improved and he was discharged home.

Setting: Tertiary care hospital

Patient: A 58-year-old male with history of drug abuse and schizoaffective disorder.

Assessment/Results: Since discharge from IPR, he had a short stay at subacute rehabilitation and then discharged home. He was still primarily using a wheelchair for mobility but able to ambulate short distances with a walker. His radiating back pain was not significantly changed since either lumbar or cervical surgery, but extremity strength and function improved.

Discussion: It is well accepted that disc herniation and spinal stenosis are common imaging findings but do not always cause clinically significant symptoms. While this patient’s history was suspicious for cauda equina syndrome, hyperreflexia was more suggestive for a proximal lesion. It is difficult to know if his lumbar surgery was necessary, as his strength and pain did not initially improve.

Conclusion: Prevalence of clinically insignificant spinal stenosis and disc protrusions is high. Careful correlation between physical exam and imaging findings is important to ensure patients receive appropriate treatment.

Level of Evidence: Level V

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PM&R Meeting Abstracts - https://pmrjabstracts.org/abstract/when-imaging-is-misleading-cervical-myelopathy-in-a-patient-with-lower-extremity-weakness-and-lumbar-spinal-stenosis/